Perioral Mound Liposuction

Q: Dr. Eppley, I am attaching some facial photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling! 

I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!

A: Thank you for sending your pictures. Your area of concern would be considered the perioral mound region and yours is a classic case of it. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients.

Having cheek dimples does not affect the results of perioral mound liposuction either positively or negatively.

Dr. Barry Eppley

Indianapolis, Indiana

Extra Large Breast Implants

Q: Dr. Eppley, I am seeking extra large breast implants. I was a natural 34H and then got 800cc silicone implants under the muscle. the dr had said it would double my size. However it didn’t change my size at all, it only gave me a tiny bit more upper pole fullness was all. So I was very disappointed with spending all this money to not be bigger which was what I wanted. I have been told by a couple of Dr’s I could go up to 2000cc with overfilled saline. Is that something you would do? Or will you not go that large on patients? I want a good plastic surgeon with good ratings like you have. I am not a tiny framed lady, I do have a curvy build. Please let me know, thanks.

A: If 800ccs breast implants did not come close to your breast size goal, then at least twice that would be needed to make a more visible difference. Overfilled saline implants would be the only way to achieve that type of volume. Where the final volume might be on the spectrum of 1600 to 2000cc depends on how it looks and feels during surgery.

Please send me some pictures of your breasts for my assessment for these extra large breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Lipedema

Q: Dr. Eppley, I heard about you when I was researching Knee Lifts. After reading more about you ,watching your YouTube and reading your Bio as well as looking at your website I think you are indeed incredibly and uniquely qualified. Unfortunately I saw nothing on your website about my problem so I will ask you directly.

I believe I have stage 1 Lipedema,. After a few years of research I believe its Lipedema, based on my symptoms, age onset and process of elimination. The only treatment for Lipedema is liposuction from what I have read and spoken to surgeons about. I am planning to get my calves and ankles treated by liposuction but the surgeon I’ve spoken to doesn’t want to touch my awful, fat, disfigured knees as he says “knees are tricky”. He also isn’t too keen on my thighs as most of the disproportionate fat is right above my knees, which he says will make my knees much worse than they already are. I am not overweight, I am healthy, athletic and in shape. I would like to know what you know about Lipedema,and what your thoughts are about this type of surgery.

Thank you for taking your time to read this and reply.

A: As you know there are differences between lipedema and lymphedema by which you have come to the conclusion that you have the latter. Some improvements in true lipedema can be obtained by liposuction as you have stated.  When it comes to using liposuction for its treatment I would be more concerned about prolonged edema from the calfs and ankles but not the knees. There is nothing ‘tricky’ about the knees and there is not any anatomic feature that makes them different for liposuction surgery. What the skin will do when the fat is reduced can not be precisely predicted anywhere on the lower extremities but most likely it is not going to shrink in a perfectly smooth manner. That would be an expected tradeoff for the size reduction.

Those are the general comments I can make without having any specific visual knowledge of your lower extremity problem.

Dr. Barry Eppley

Indianapolis, Indiana

Lip Enhancement

Q: Dr. Eppley, what are the differences between lip ‘advancement’ and lip ‘enhancement’ and lip ‘lift’? I’m specifically looking to augment my upper lift for more fuller appearance.

A: In answer to your questions, lip enhancement is a global term that refers to any type of lip augmentation procedure, albeit injection or surgical.

A lip advancement, also known as a vermilion advancement or ‘gull wing’ procedure removes skin just above the upper lip and the vermilion or red part of the lip is moved up to cover the removed skin area. This increases vermilion show from one mouth corner to the other. In essence it pushes the vermilion towards from below.

A lip lift, also known as a subnasal lip lift or ‘bullhorn’ lip lift removes skin from below the nose and lifts the lip upward. It shortens the distance between the nose and the upper lip and improves the central vermilion fullness of the upper lip. It does not have any effect on the sides of the upper lip.

I would need to see pictures of your lip to determine which lip enhancement procedure may be best for you. Most patients graduate to surgical lip enhancement after trying injectable lip enhancement methods.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Asymmetry

Q: Dr. Eppley, I am interested in correcting my jawline asymmetry.  I’ve always hated taking pictures head on or from the right side of my face because of the asymmetry of my chin and the angle of my jaw on the right side. It’s almost as if my jaw has shifted down and has caused my chin to shift and protrude forward on one side.  This has been the case for as long as I can remember and I almost feel as if it’s getting worse. Probably because my skin is thinning and I can see the outline of the chin a little more. I’ve never had any dental issues or braces and no dentist has ever told me my bite needed to be corrected. I just wanted to find out my options-and see if this was actually possible to fix. Thank you so much in advance!

A: Thank you for sending your pictures and describing your lower jawline asymmetry concerns. What you have is an overgrowth of the right lower jaw that makes the jaw angle slightly bigger,  the right jawline lower and the chin shift to the left. Usually with such jaw overgrowth there would be associated bite and occlusal plane asymmetry…but you seem to have largely avoided that typical accompanying issue. The treatment would be one of a chin and jawline bone shave from the left side of the chin all the way back to the jaw angle. This would be done through a submental incision approach. The amount of bone to remove would be determined from a simple panorex x-ray based on millimeter comparative measurements of he height of the mandible from midline chin to the ramus.

Dr. Barry Eppley

Inianaopolis, Indiana

Jaw Implant

Q: Dr. Eppley, I have consulted with you many times about my facial structure and have plans to do the jaw implant. I’m just wondering if I already have surgeries on my chin (1st surgery sliding genioplasty. 2nd surgery reverse sliding genioplasty 3rd surgery shaved the corner of the chin from expansion as it made my chin becomes square) will it be safe to do the jawline implant? Not doing anything with the chin but maybe will be the same area that got cut several times. Will it increase the risk of infection? I don’t plan to do jaw inplant with any doctor in Korea or anywhere as I think a doctor with experience is the best. And I had to save up again and again after my previous failure for other parts.

I really plan to do it but will be about a year or two from now since I have to finish my braces first in another country. 

A: Regardless of your prior chin surgeries, that does not preclude you from getting a jaw implant in the future. The custom jawline implant is made from a current 3D CT scan so this will show your current bony anatomy. That happened to the chin bone in the past does not affect placing an implant across it in the future. 

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, I am interested in a custom jawline implant. I am attaching a few photos of my face and you will see that my lower third is narrow. My general interest is in a wraparound jaw implant in order to widen the face, tighten up the submental, improve aesthetics of the face and protrude the chin to balance the protrusion of the nose. What does your aesthetic eye think of this possibility judging by my photos?

Do the custom made implants have a high success rate as in the forum for plastic surgery knowledge I frequent there is a patient from Western Europe of yours that has had 2 revisions to his jaw implants in the span of 7 months? He says its “finetuning to look natural”. I am not extremely interested in having it revised because I dont want to endure the whole ordeal again.

A: If you are looking for increased lower facial width and dimensions of the chin and jaw angles that has a smooth linear connection than a custom jawline would be the preferred choice.

It is not uncommon for many patients to have revisions of custom facial implants including custom jawline implants. This is primarily because they often don’t know what they really want until they wear it to so speak. In the case you so described the patient himself chose the dimensions and that was what was exactly provided to him…only later to decide he wanted a different look. (Less strong)

The key in any custom jawline implant is that less is more. It is always to better to go smaller in dimensions as its effect is more substantial than a patient can anticipate. In looking at your face that its exactly what you…a smaller custom jawline implant. I cll this type a ‘jawline defining implant’ as it just adds angularity and a little width.

Dr. Barry Eppley

Indianapolis, Indiana

Zygomatic Arch Implants

Q: Dr. Eppley, I have put some thought into those measurements you told me about regarding zygomatic arch implants. I have made some research of my own and I have a found a cheek implant from Stryker that is not far from being a zygomatic arch implant. It’s measurements are close to the ones you suggested  for me and my aesthetic goals (yours: 5cm length / 6-8mm width / 5mm projection height) which I assume can be carved/cut to meet your measurements even more.

Despite doing all of that sizing modification, the implant isn’t originally designed to sit on top of the zygomatic arch only. (This implant is also slightly bent in its shape). In the sample photo above, you can see that it is positioned in a way that starts just halfway on the zygomatic arch, going further over the malar prominence, whereas it ends at the maxillary buttress.

My question is; after the surgeon have carved/cut this implant to meet the sizing recommendations you sort of suggested, is it even acceptable to position this implant on the entire zygomatic arch?

A: I would be very cautious about using a Medpor material as a zygomatic arch implant. Besides the issue of its natural underlying shape (curved), the tissue ingrowth from this material will make it virtually impossible to ever remove or revise it later. There is a branch of the facial nerve that crosses over the posterior zygomatic arch that supplies movement to the forehead. While there is a very low risk of injuring this nerve during the insertion of the implant, trying to remove a Medpor zygomatic arc implant later due to the tissue ingrowth will almost certainly increase that risk considerably. If injured there will be some paralysis of the forehead. Thus this is not a material I can endorse as a zygomatic arch implant. Easy reversibility of a facial implant can be an important feature whose importance varies based on the anatomic facial location of placement.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I hate to say it but I’m second guessing my decision about rhinoplasty surgery the more I read online.  Perhaps I shouldn’t be reading online but I’m reading things like “nose job is the worst possible procedure to have done for a male.”. And that the problem is a lack of facial bone growth, not a big nose, which in my case is certainly true as I have a narrow face and underdeveloped lower third.  So I’m wondering will a rhinoplasty simply be a regression for me, further feminizing my face?  I know ultimately it’s my decision but obviously you understand aesthetics better than I do and could offer some sort of assurance as to why a rhinoplasty would be beneficial for me.

A: The psychological preparedness of a patient before any aesthetic surgery is of great relevance. A patient’s behavior will follow after surgery the exact pattern that they had before surgery. This is a plastic surgery experience that we see on a near daily basis.

 It is one thing to be anxious about the surgical process, which most people normally are, but to be questioning whether one should have surgery at all based upon an uncertainty about the facial changes speaks to a different level of anxiety. It is important to realize that almost every patient after elective aesthetic facial surgery goes through a point in their recovery where they question the wisdom of their choice. For those who have few doubts before surgery they get past it at some point in their recovery. For those that were internally questioning whether such facial changes would be beneficial at all,  they may never get past it and may recover to regret having had surgery. This is relevant since rhinoplasty is an irreversible change. It is not like a cheek or chin implant which can be pulled out later. This its why computer imaging should always be done before rhinoplasty which can help the patient visually determine if the surgery is worth it.

Dr. Barry Eppley

Indianapolis, Indiana

Mouth Widening Surgery

Q: Dr. Eppley, I am interested in a lateral commissuroplasty (mouth widening surgery) as I have a small mouth. How risky is this procedure in terms of end results? Does it always leave visible scars? And how visible are these scars? Will the scars heal evenly on both corners of the mouth? I’m curious to see some before and after photos of this procedure as I could not find any online.

I am also wondering about functionality after the procedure. How will smiling, eating, talking potentially be affected? Will there be a problem with drooling?

Thank you for your time!

A: Thank you for your inquiry. An opening lateral commissuroplasty or mouth widening procedure works because it removes a triangular segment of skin at the sides of the mouth and moves the vermilion of the mouth corner outward. By definition this leaves a v-shaped incision line at the mouth corner and a resultant fine line scar at the vermilion-cutaneous border. How discrete that mouth corner scar looks can vary but does well most of the time. Regardless of how they heal they cause no functional issues and do not interfere with eating, talking or smiling.

Dr. Barry Eppley

Indianapolis, Indiana